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WELL/PUMP PERMITC �? L►� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTO�5-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS /� /� CITY/ZIP <br /> CROSS STREET ,LPN �j,G�j �/3 f U(�A USE APPLICATION# <br /> J , ARCEL SIZE ND <br /> OWNER NAME f,/f-� /�2�� PHON �� /JJ/ <br /> OWNER ADDRESS jGa CITY/STATE/ZIP_ �(� <br /> CONTRACTOR //�/// � � ` PHONE2�j�} <br /> CONTRACTOR ADDRESS_ / �L�i9jt- CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT `�- PHONE �"-- <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP �t <br /> LICENSE PC-57 W-61 1-1 D-09 ❑ Other NUMBER 611A EXPIRATION DATE_/;,3 <br /> BILLING PARTY: OWNER i i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391)j ' Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other __P <br /> # IAMB.. <br /> ❑ Monitoring Well(s) #of wells I,I Soil Boring(s) <br /> of borings ,f_ ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair M <br /> ❑ New Pump 'urnp Replacement ❑ Pum Repair ❑ Raise Well Casing <br /> ID <br /> WELL CONSTRUCTION 2 <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN 9?A J <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size HR�� TY <br /> ❑ Conductor Casing n diameter / Conductor Casing Depth ft <br /> �LZH p`cPA F T <br /> Well Casing Diameter— in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> f PUMP ��bmersible❑ Turbine ❑ Other _ HIP===j Pump Set—_,4-Q—ft Standing Water Level ft <br /> I HEREBY CE TIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH-THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI H DVANCE NOTICE REQUIRED F7&11+� <br /> SPEECTIONS -PLEASE CALL(209)95 -7 97 <br /> SIGNED TITLEDATE /, <br /> 05, <br /> ALS YARTME <br /> T USE/ONLY <br /> Application Accepted By -- e �11 AreaEmployee ID#9A� <br /> _ — <br /> Grout Inspection ByDate 1 PECIAL ell Permit <br /> Pump Inspection Byk_V06baelnDate I I I 19 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChe Amount Permit/ <br /> Code& Info11Vmash Remitted Dae Service Re uest# Invoice# " Well ID# <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />